LEARNING MODEL OF HOSPITAL CLINICAL PRACTICE FROM STUDENT AND CLINICAL EDUCATOR POINT OF VIEW : A QUALITATIVE STUDY ( Model Pembelajaran Praktik

Introduction: Qualifi ed education is characterized by qualifi ed teaching and learning in the classroom, laboratory, and clinical practice. Producing nurses who are able to provide professional nursing care for patients requires learning process in practice by using learning models. The purpose of this study was to explore the experience and expectation of students and clinical instructors on practices learning model in Ners Program of STIKES Bali. Method: This study used qualitative design with phenomenology approach. There were 8 participants from students and clinical instructors selected by purposive sampling. Data were collected by in-depth interviews. Data were transcribed and analyzed using thematic analyses. Results: Findings indicated that there were fi ve themes related to a student and clinical instructor’s experience and expectation about practices learning model. The themes were supporting from institution and clinic, bed side teaching (BST), conference, lack of time of clinical instructor in supervising, and case study. BST, conference, and case study were some of the learning models implemented in clinical practices. These methods will run properly if there are good supporting and optimal supervising. Discussion: BST, conference, and case study are appropriate methods for clinical teaching. Lack of time in supervising is one of the barriers found. It is essential for clinical instructors to spend suffi cient time to supervise students in clinical practice.


INTRODUCTION
Qualified education is characterized by the quality of teaching and learning in the classroom, laboratory and clinical practice.The aim of the learning process in the classroom is to enhance student's knowledge to deliver good nursing care.Whereas, in clinical practice is to improve student's skills in providing nursing care.These goals are related to the higher nursing education of Indonesia's goal.It is to produce nurses who are able to provide professional nursing services to patients (Karim & Utomo, 2014).For achieving the goal, every institution should provide opportunities for students to apply their knowledge in the clinical practice.It is needed to apply practices learning models to give experiences for students in managing proper health care.
The practices learning models used in clinical teaching are conferences, bed side teaching (BST), demonstration, and case study.These methods have benefits and disadvantages.The conference focuses on group discussion about the patient case which is started with pre conference post conference (Nursalam, 2007).BST is a method of small discussion with patient and students.In the BST method, a number of participants are limited (5 to 6 participants) which is pre conference and post-conference conducted in front of the patient.This method is a method usually used after demonstration proceed.Before performing this method required physical preparation, the psychology of students and tutors (Nursalam & Efendi, 2009).
Based on the literature reviewed, Ekawati (2010) found that written clinical assignment was the largest contribution (38.64%) on the level of student satisfaction in the nursing clinical learning experience.Conference contributed to the second level of student satisfaction (31.46%).Implementation of BST was the smallest contribution (21.70%) on the level of student satisfaction.In addition, Maysarah (2014) stated that there were in average level (43.3%), good level (26.7%) and poor level (30%).Furthermore, for BST, there were 46.7% had an average level, 20% had a good level, and 33.3% had a poor level.A preliminary study conducted in March 2016, from 10 students who took ners program, there were 7 students preferred BST and others liked conference, demonstration, and nursing rounds.
According to previous studies, there were a lot of studies focused on quantitative study (Aryanty & Uladari, 2013;Yusiana and Damayanti, 2013).but a limited study on qualitative research.While qualitative research can provide information subjectively from participants' itself (Kamaryati, Susanti, and Suyasa, 2015).Therefore, this study is necessary to conduct for contributing to education development especially on Ners Program to produce graduates who are competent and competitive in national and international level.The aim of this study is to explore the experiences and expectations of students and clinical instructor of practices learning model in Ners Program at STIKES Bali.

METHOD
This study used a qualitative method with a phenomenological approach.There were 8 participants involved by purposive sampling.The participants consisted of 5 students and 3 clinical instructors.The inclusion criteria were STIKES Bali students who are taking ners program, willing to be participants in the study by completing the informed consent.Whereas, clinical instructors (CI) were lecturers or practitioners in a clinical setting.

Procedure and Research Etick
This study is approved by ethic committee.Furthermore, researchers contacted potential participants.Potential participants were given an explanation of the research, goals, and procedures of the study.After they had understood all of the information, they were asked to sign a consent form.This study conducted at STIKES Bali and hospitals on June to July 2016.The study used in-depth interviewed method by using the list of questions that have been created by researchers.Confidentiality of the participants is considerable concern in the study.
Data were analyzed to explore experience and expectation's students and clinical instructors on practices learning models.Code of participants was created and transcribed the data from recorder manually.After finishing transcription, data analyzed to find themes.

RESULT
After analyzing and tracing themes, the study identified five themes, 1) Supporting from institution and clinic, 2) BST, 3) Conference, 4) Lack of time in supervising, 5) Case Study.

DISCUSSION
Institution and clinical practice support are needed in the learning process on ners program.Good support from both sides will give good impact as well for students or learners who are implementing clinical practices.The research found that the support provided by the institution was very good.It is proved by some of the participants (M.01 and M.02) stated that "... provide competent lecturers in their expertise, ... if there were a lack of equipment in the clinical setting, institution provided it ... ".On the other hand, good support was provided by the hospital.Some participants (M.04, D.02, and C.01) said that "... the hospital already had a room for practicing some models, ... equipment is provided, ... CIs were competent, ... help get target...".This maybe the educational institutions and hospitals already have a joint commitment to applying some models of clinical learning.Without good support from the hospital as a provider of the learning environment in the clinic, students can not practice the models of learning acquired during their academic education.Henderson et al. (2011) stated that the clinical learning environment is very important because students not only practice the skills alone, but students learn about practical norms in providing nursing care.
BST is a learning model that provides opportunities for students to deal directly with patients (Nuzulianva, Diniyah, and Herfanda, 2015).Most participants said that BST was the most learning model applied to ners program.The reason is when the BST is done, various aspects of learning can be applied, for example, knowledge, communication, and the ability of clinical skills.The same is conveyed by Nuzuliana et al. (2015), BST was an appropriate method to be able to practice skills for clinical aspects, communication, and ethical.
The other of learning models in clinical practice is a conference.This method is often used when management practices in hospitals (Permatasari, Suryani, and Wulandari, 2014).The method gives a good learning experience for students in which students are prepared first before going clinical setting.After completing the practice, they can make an evaluation of all activities based on the achieved goals.The participants also expressed the same things both on pre and post conference.It may lead students to gain experience in clinical practice.
A case study is a clinical method of learning.This model has been developed by educational institutions to develop students' ability for enhancing their critical thinking.When interviewing some participants, they said that the case study focused on training and developing the critical thinking of students in different cases.This method can also increase student confidence in managing patients or cases especially to analyze and solve the problems (Permana, Sumarwati, and Setiyani, 2016).Even though, this method will be better to apply when it's implementation is combined with other methods.The same statements came from Nielsen et al. (2013), they stated that learning process by using case study could improve good attitudes, skills, and communication in interacting with the patient.The creativity of students in a clinical setting was the main point in improving problemsolving for students (Chan, 2012).
Implementation of teaching models in clinical practice is strongly influenced by the supervising role.This study found that lack of time in supervising from clinical instructors both from the institution and clinical practice.Some participants stated that it was difficult to meet with two of clinical instructors in the same time.This is possibly due to the workload.High workload gives impact in meeting with students.This could be an obstacle in implementing models of learning in ners program

CONCLUSION
Based on the findings and discussion can be concluded that some models of practical learning such as BST, Conference and case study are very suitable conduct in the ners program.However, this process will run smoothly if there was good support from the institution (STIKES Bali) and student practice environment.But one obstacle that was found in the study is a lack of time of clinical instructors to supervise the students.Therefore, it is expected for the clinical instructor to provide adequate time to supervise students.(PDPI 2011;Notoatmodjo 2003) .. saya rasa pendekatannya enggak pas gitu ya... karena semuanya memiliki keunggulan dan kekurangan jadi gk bisa kita grade kan... jadi tergantung tujuan dari bimbingan kepada mahasiswa.. ee.